Multiple pregnancies in patients with rheumatic or congenital heart disease

Abstract

A group of fifty-three cardiac patients who had four or more pregnancies have been studied. All of these women had rheumatic heart disease with the exception of one patient who had idiopathic pulmonary arterial dilatation. These patients had a total of 364 pregnancies or nearly seven pregnancies per patient. The maternal mortality was only 1.3 per pregnancy and only one of the five deaths was related to congestive heart failure. Congestive heart failure occurred in fifteen of the fifty-three patients or in forty-one of the 364 pregnancies (11.3 per cent), an incidence less than that usually reported in cardiac patients. Our findings suggest that these women were able to tolerate the burden of pregnancy better than the average cardiac woman in the childbearing period. Congestive heart failure did not increase in frequency as the number of pregnancies increased, a finding which confirms the belief that parity per se bears no direct relationship to the development of heart failure. The age of the patient, the duration of the rheumatic state, and the number of attacks of rheumatic fever all seem more important factors influencing the course of the pregnancy in the cardiac patient than the actual number of pregnancies she has borne previously. Auricular fibrillation was uncommon in this special group of patients with multiple pregnancies, a fact suggesting they were in a relatively early stage of the natural history of their rheumatic heart disease. Congestive failure occurred much more commonly in the unfavorable (52 per cent) than in the favorable (4.7 per cent) group. In all of the pregnancies which came to full term delivery was accomplished by the vaginal route with the exception of three cesarean sections performed for obstetric reasons. This confirms the belief that in cardiac patients operative delivery should be performed primarily for obstetric indications. The ultimate life span was greater and the incidence of subsequent congestive failure was less in those women who were able to tolerate multiple pregnancies without developing cardiac decompensation than in those who had heart failure. This series of patients indicates that multiple pregnancies are compatible with a considerable life expectancy in some women with heart disease. It is emphasized, however, that in considering the problems of pregnancy every patient with heart disease must be evaluated individually in the light of many factors including her age, the duration of the rheumatic state, the nature of the orginal rheumatic disease, the cardiac reserve, and the course of earlier pregnancies.